Provider Demographics
NPI:1831136308
Name:RABURN, DERRICK WAYNE (PT)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:WAYNE
Last Name:RABURN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:RABURN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:78078 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-8173
Mailing Address - Country:US
Mailing Address - Phone:760-345-9934
Mailing Address - Fax:760-345-3086
Practice Address - Street 1:78078 COUNTRY CLUB DR
Practice Address - Street 2:SUITE 205
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-8173
Practice Address - Country:US
Practice Address - Phone:760-345-9934
Practice Address - Fax:760-345-3086
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT202413OtherPPIN - MEDICARE #
CAP50817Medicare UPIN